Every finding on record at Heart of Hospice LLC

Based on record review and interviews,, the hospice failed to ensure an initial patient assessment was conducted within 48 hours of the patient's signed notice of election (NOE) by the Registered Nurse (RN) for one of 19 patients reviewed (Patient 6) --- The findings include: Record review on 07/24/23 at 3:06 PM for Patient 6 revealed Patient 6 was admitted on 03/15/23 for Hypertensive Heart Disease. Review of documentation revealed the RN started documentation on 03/15/23 at 11:59 AM and completed documentation on 03/17/23 at 3:38 PM, which was 51 hours after the patient signed the notice of election. During an interview on 07/27/23 at 10:56 AM, the Hospice Regional Quality Coordinator verified the findings.

Based on record review and interview, the hospice failed to ensure the interdisciplinary team (IDT) completed the patient's initial comprehensive assessment within 5 days of the patient's notice of election (NOE) for 10 of 19 patient charts reviewed. (Patient 1, 2, 3, 6, 7, 10, 11, 12, 13, and 17) --- The findings include: Record review on 07/25/23 at 12:28 PM of P 1 revealed P 1 was admitted to the hospice on 02/09/23 for Congestive Heart Failure. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 02/17/23, 7 days after the NOE. During an interview on 07/27/23 at 10:28 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/25/23 at 1:10 PM of P 3 revealed P 3 was admitted to the hospice on 02/07/23 for Chronic Obstructive Pulmonary Disease. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 02/10/23, while the Masters Social Worker (MSW) assessment did not occur until 02/13/23, 6 days after the NOE. During an interview on 07/27/23 at 10:37 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/24/23 at 3:06 PM of P 6 revealed P 6 was admitted to the hospice on 03/15/23 for Hypertensive Heart Disease. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 03/24/23, 9 days after the NOE. During an interview on 07/27/23 at 10:56 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/24/23 at 2:17 PM of P 7 revealed P 7 was admitted to the hospice on 05/17/23 for Atherosclerotic Heart Disease. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 06/02/23, 16 days after the NOE. During an interview on 07/27/23 at 11:19 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/25/23 at 2:13 PM of P 10 revealed P 10 was admitted to the hospice on 03/08/23 for Malignant Neoplasm of frontal lobe. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 03/10/23, while the MSW assessment did not occur until 03/13/23. During an interview on 07/27/23 at 11:33 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/26/23 at 9:05 AM of P 12 revealed P 12 was admitted to the hospice on 04/07/23 for Alzheimer Disease. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 04/21/23, 14 days after the NOE. During an interview on 07/27/23 at 12:00 PM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/26/23 at 10:00 AM of P 13 revealed P 13 was admitted to the hospice on 03/28/23 for Senile Degeneration of Brain. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 04/07/23, 10 days after the NOE. During an interview on 07/27/23 at 12:10 PM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/26/23 at 1:53 PM of P 17 revealed P 17 was admitted to the hospice on 05/12/23 for Hypertensive Heart Disease. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 05/26/23, 14 days after the NOE. During an interview on 07/27/23 at 12:20 PM, the Hospice Regional Quality Coordinator verified the findings. On 7/24/23, at 2:00 PM Patient 2's record was reviewed. Patient 2 elected hospice care on 5/19/23 with a diagnosis of Pulmonary Fibrosis. The initial Medical Social Worker visit was on 5/31/23 (12 days after election of hospice care). During an interview with the Director of Clinical Services (DCS) on 7/27/23, at 11:44 AM, she/he confirmed the findings. On 7/26/23, at 9:15 AM Patient 9's record was reviewed. Patient 9 elected hospice care on 8/17/21. The initial MSW and initial Chaplain visits were conducted on 8/23/21 (6 days after election of hospice care). During an interview with the DCS on 7/27/23, at 11:17 AM, she/he confirmed the findings. On 7/28/23, the hospice policy titled, "INITIAL & COMPREHENSIVE ADMISSION ASSESSMENT & PLAN OF CARE," was reviewed. The policy indicated, "...The comprehensive assessment will be completed no later than 5 calendar days after the date of election of hospice services...The...MSW...will complete a psychosocial evaluation...no later than 5 days after the date of hospice election as part of the comprehensive assessment...the Chaplain will complete the spiritual evaluation...no later than 5 days after the date of hospice election..."

Based on observation, record review, and interview, the hospice failed to promote the hospice patient's well-being when the Registered Nurse (RN) did not perform a physical assessment when he/she reported pain after a fall for one of four home visits (Patient 8). --- On 7/25/23 at 11:05 AM, a home visit was made with Registered Nurse (RN) 2 to Patient 8. Patient 8's caregiver (CG)/ responsible party (RP) stated Patient 8 "...had a bad fall...". Patient 8 stated he/she had pain and "bruising" to his/her right chest "where the cancer is." Patient 8 placed his/her left hand on his/her right chest and right torso under his/her right arm when he/she stated this. Patient 8 was wearing a shirt, but RN 2 did not observe the area Patient 8 indicated. On 7/26/23 at 9:00 AM, Patient 8's record was reviewed. Patient 8's Hospice Certification and Plan of Care (HCPOC)for the benefit period dated 5/10/23 to 7/8/23, showed, "...THE PRINCIPAL HOSPICE DIAGNOSIS IS SARCAMATOID MESOTHELIOMA (lung cancer) STAGE IV...MASSES IN CHEST CAVITY BETWEEN RIBS 3/4 AND 4/5, LINING TO HEART AND LYMPH NODES...". On 7/27/23 at 10:48 AM, an interview was conducted with the Director of Clinical Services. The DCS confirmed RN 2 should have observed and assessed Patient 8's chest area where he/she complained of pain after a fall.

Based on record reviews and interviews, the hospice failed to ensure reconciliation of the patient's hospice medication profile with the assisted living facilitys medication administration record (MAR) for 1 of 1 patient in a nursing care facility (Patient 7) and the actual home medications for 2 of 3 home patients (Patient 6 and 8). --- The findings include: Home observation on 07/25/23 at 10:25 AM to 11:45 AM of P 6 revealed P 6s home medications P 6 is no longer taking while compared to the hospice MAR: Laxative stool softener with Senna 8.6 mg (milligrams)-50 mg; take 1 tablet twice daily, Lorazepam 0.5 mg; take 1 tablet every 6 hours as needed for anxiety or dyspnea, Morphine concentrate100 mg/5ml (milliters) (20 mg/ml) oral solution; take 0.2 ml every2 hours as needed for severe pain or dyspnea, Promethazine 25 mg tablets; take 1 tablet every 6 hours as needed for nausea or vomiting, and Robinul 1 mg; take 1 tablet every 6 hours as needed for secretions. Further observation revealed the following listed medications on the hospice MAR which P 6 is taking not listed on the MAR: Magnesium 400 mg; take 1 tablet by mouth every day, Zarolyn 5 mg; 1 tab every morning as needed for swelling, Centrum Mens tablet; take 1 tablet every day, Tylenol 8 hour; take 1 tablet as needed for pain, and Nasal spray; 1 squirt each nostril once a day as needed. During an interview on 07/27/23 at 10:56 AM, the Hospice Regional Quality Coordinator verified the findings. Facility observation on 07/25/23 at 9:35 AM to 10:03 AM of P 7 revealed P 7s facility medications of Famotidine 20 mg; take 1 tablet by mouth every 2 days while compared to the hospice MAR of Famotidine 20 mg; take 1 tablet by mouth every other day; Lacosamide 150 mg tablet; take 1 tablet by mouth twice daily while compared to the hospice MAR of Lacosamide 100 mg; take 1 tablet twice a day; and Levetiracetam 750 mg; take 2 tablets by mouth twice a day while compared to the hospice MAR of Levetiracetam 750 mg tablet; take 1 tablet every 12 hours as needed for seizures. Further observation revealed the following medications listed on the assisted living MAR and not on the hospice MAR: Allergy reli tab 10 mg; take 1 tab daily; Amlodipine 5 mg tab; take 1 tab by mouth daily, aripiprazole 10 mg; take 1 tab once daily, Metamucil packets; take 1 packet by mouth once a day, Thera M Plus; take 1 tablet by mouth once daily, Timolol solution 0.5 %; Instill 1 drop in each eye twice a day, Acetaminophen 325 mg tab; take 1 tablet by mouth every 4 hours as needed, Lorazepam 0.5 mg tab; take 1 tablet by mouth every 6 hours as needed for anxiety, and Diclofenac gel 1%; apply to affected area twice a day. During an interview on 07/27/23 at 11:19 AM, the Hospice Regional Quality Coordinator verified the findings. On 7/25/23, at 11:05 AM a home visit was made to Patient 8 with Registered Nurse (RN) 1. A review of the hospice plan of care medication list and the medications in the home revealed discrepancies. Ipratropium 0.5 mg/albuterol 3 mg nebulized solution was on the medication list but Patient 8's caregiver (CG) stated he/she had "...not had or used that..." since before admission to Hospice. Medications Patient 8 was prescribed and was taking but were not on the hospice plan of care medication list were as follows: certrizine 10 mg one orally each day, fill date 6/27/23; bisacolax 10 mg suppository, fill date 6/20/23; lorazepam 1 mg 0.5 to 1 tablet (0.5-1 mg) orally every 3-4 hours as needed, fill date 3/29/23 - the CG states Patient 8 takes this "every day;" and novolog insulin sliding scale, 5 units if blood sugar (BS) greater than 200 and 9 units if BS greater than 300 - Patient 8 states he/she has taken this for years. Marinol 5 mg twice a day was on the medication list, but the bottle label indicated three times a day with a fill date of 7/13/23. Oxygen was on the medications list at 3 liters but Patient 8 and his CG stated he/she was using 4 liters "forever" and then it was increased to 5 liters "about a month ago." During a concurrent interview with RN 1, she/he confirmed the findings. On 7/28/23, the hospice's policy titled, "MEDICATION ADMINISTRATION," was reviewed. The policy indicated, "...The RN will initiate a medication profile upon admission and will update with any changes throughout the course of care..."

Based on record reviews and interview, the hospice failed to ensure the Interdisciplinary Group(IDG) contained core members for 5 of 14 patient charts reviewed. (Patient 7, 10, 11, 12, and 13) --- The findings include: Record review on 07/24/23 at 2:17 PM for Patient 7 revealed the patient was admitted on 05/17/23 for Atherosclerotic Heart Disease. Review of the certification period dated 05/17/23 to 08/14/23 revealed there was no Master Social Worker (MSW) present for the IDG meeting on 07/14/23. During an interview on 07/27/23 at 11:19 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/25/23 at 2:13 PM for Patient 10 revealed the patient was admitted on 03/08/23 for Malignant Neoplasm of frontal lobe. Review of the certification period dated 06/06/23 to 09/03/23 revealed there was no MSW present for the IDG meeting on 07/14/23. During an interview on 07/27/23 at 11:33 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/25/23 at 3:11 PM for Patient 11 revealed the patient was admitted on 09/20/22 for Oropharynx Cancer Stage IV. Review of the certification period dated 05/18/23 to 07/16/23 revealed there was no MSW present for the IDG meeting on 07/14/23. During an interview on 07/27/23 at 11:43 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/26/23 at 9:05 AM for Patient 12 revealed the patient was admitted on 04/07/23 for Alzheimer Disease. Review of the certification period dated 06/06/23 to 08/04/23 revealed there was no MSW present for the IDG meeting on 07/14/23. During an interview on 07/27/23 at 12:00 PM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/26/23 at 10:00 AM for Patient 13 revealed the patient was admitted on 03/28/23 for Senile Degeneration of Brain. Review of the certification period dated 05/27/23 to 07/25/23 revealed there was no MSW present for the IDG meeting on 07/14/23. During an interview on 07/27/23 at 12:10 PM, the Hospice Regional Quality Coordinator verified the findings.

Based on record reviews and interview, the hospice failed to ensure the Skilled Nurses (SN), Master of Social Worker (MSW), Chaplain, Hospice Aide (HA), and Volunteer completed home visits per the ordered frequency on the patient's plan of care for 6 of 14 patient charts reviewed (Patient 6, 7, 10, 11, 12, and 17) and the plan of care was not followed due to a change in 1 of 14 patient conditions (Patient 7). --- The findings include: Record review on 07/25/23 at 12:28 PM for Patient 6 revealed the patient was admitted on 03/15/23 for Hypertensive Heart Disease. Review of the certification period dated 03/15/23 to 06/12/23 revealed the MSW visit frequency was 3 times a month for 2 months. Review of Patient 6s visits revealed 1 missed MSW the month of April 2023. During an interview on 07/27/23 at 10:56 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/24/23 at 2:17 PM for Patient 7 revealed the patient was admitted on 05/17/23 for Atherosclerotic Heart Disease. Review of the certification period dated 05/17/23 to 08/14/23 revealed the HA visit frequency was 2 times a week for 12 weeks. Review of Patient 7s visits revealed 2 missed HA visits the week of 06/11/23 to 06/17/23. During an interview on 07/27/23 at 10:56 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/25/23 at 2:13 PM for Patient 10 revealed the patient was admitted on 03/08/23 for Malignant neoplasm of frontal lobe. Review of the certification period dated 06/06/23 to 09/03/23 revealed the HA visit frequency was 2 times a week for 1 week, RN frequency 2 times a week for 1 week, and Chaplain frequency 1 time every 2 months for 2 months. Review of Patient 10s visits revealed 1 missed HA visit the week of 06/06/23 to 06/10/23 and 1 missed visit the week of 06/11/23 to 06/17/23; 1 missed RN visit the week of 06/11/23 to 06/17/23; and 1 missed Chaplain visit the month of June 2023. During an interview on 07/27/23 at 10:56 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/25/23 at 3:11 PM for Patient 11 revealed the patient was admitted on 09/20/22 for Oropharynx Cancer Stage IV. Review of the certification period dated 05/18/23 to 07/16/23 revealed RN visit frequency was 1 time every 2 weeks for 2 weeks, HA visit frequency 2 times a week for 8 weeks, and Chaplain visit frequency 1 time every 2 months for 2 months. Review of Patient 11s visits revealed 1 missed RN visit the week of 05/28/23 to 06/03/23, 2 missed HA visits the week of 05/28/23 to 06/03/23 and 06/11/23 to 06/17/23, and 1 missed Chaplain visit the month of June 2023. During an interview on 07/27/23 at 11:53 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/26/23 at 9:05 AM for Patient 12 revealed the patient was admitted on 04/07/23 for Alzheimer Disease. Review of the certification period dated 06/06/23 to 08/04/23 revealed the HA visit frequency was 2 times a week for 8 weeks. Review of Patient 12s visits revealed 1 missed HA visit the week of 06/06/23 to 06/10/23 and 2 missed HA visits the week of 06/11/23 to 06/17/23. During an interview on 07/27/23 at 12:00 PM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/26/23 at 1:53 PM for Patient 17 revealed the patient was admitted on 05/12/23 for Hypertensive Heart Disease. Review of the certification period dated 05/12/23 to 08/09/23 revealed the RN visit frequency was 1 time a week for 13 weeks, and MSW visit frequency 1 time a month for 2 months. Review of Patient 17s visits revealed 1 missed RN visit the week of 07/02/23 to 07/08/23 and 1 missed MSW visit the month of June 2023. During an interview on 07/27/23 at 12:20 PM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/24/23 at 2:17 PM for Patient 7 revealed the patient was admitted on 05/17/23 for Atherosclerotic Heart Disease. Review of Patient 7s chart revealed Patient 7 was admitted to a local hospital on 06/07/23 to 06/09/23 for seizure activity. Further review revealed the patient returned to his/her home at the assisted living facility on 06/09/23 with no visit from a nurse until 06/15/23. Review of Patient 7s plan of care (POC) revealed, ";Need for O/A (observation/assessment) of declining status/imminent death" with an intervention of ";Assess visit frequency for disciplines to determine if an increase in visit frequency is needed due to imminent death." During an interview on 07/27/23 at 1:30 PM, the Director of Clinical Services stated, ";When a patient returns from the hospital, we do a tuck-in visit." Record review on 07/26/23 at 9:05 AM for Patient 12 revealed the patient was admitted on 04/07/23 for Alzheimer Disease. Review of the certification period dated 06/06/23 to 08/04/23 revealed Patient 12 had a right great toe amputation on 04/07/23 with physician orders for ";Dakins Solution 0.5 % (percent); apply topically daily to right foot wound." Review of Patient 12s ";Wound Assessment Tool Report" revealed one wound measurement and assessment on 06/29/23 during this certification period. During an interview on 07/27/23 at 12:00 PM, the Hospice Regional Quality Coordinator stated, ";Wound care is to be done weekly preferably by the same nurse". Hospice policy, entitled, ";Wound Assessment, Documentation and Photography", revealed, ";3. Document the following in the medical record: a. Treatment and condition of the wound (each visit) ...c. Wound measurements (weekly) including the length, depth, and width of the wound in centimeters...g. Stage the wound weekly...".

Based on observation, interview, and review of hospice policy and procedure, the hospice failed to ensure ongoing sharing of information with a non-hospice provider furnishing services to 1 of 1 patient observed at the assisted living facility (ALF). (Patient 7) --- The findings include: Observations on 07/25/23 from 9:35 AM to 10:03 AM revealed Patient 7 was admitted 05/17/23 for Atherosclerotic Heart Disease. Review of the ALF's hospice chart revealed there was no physician certification, recertification information, and no hospice physician or attending physician orders. During an interview on 07/25/23, the ALF Health and Wellness Director stated, ";The information is faxed to us, and then the marketer brings copies from the office when she/he comes once a week. I discard the faxed copies when she/he puts the other ones on the chart." Hospice policy, entitled, ";Hospice Care in the Nursing Home/Skilled Nursing Facility Setting", revealed, ";7. The Hospice Agency will provide the Nursing Home/Skilled Nursing Facility with the following information on each Hospice patient: c. Physician certification and recertification of the terminal illness...g. Hospice physician and attending physician (if any) orders...".

Based on observation, interview, and review of the hospice policies, the hospice failed to ensure accepted principles for infection control were followed to prevent cross transmission of infectious agents in the home setting for three of four home visits (Patient 6, 7 and 9). --- The findings include: Observation on 07/25/23 at 10:25 AM to 11:15 AM of P 6 revealed P 6 was admitted to the hospice on 03/15/23 for Hypertensive Heart Disease. Observation of P 6 revealed RN 1 entered P 6s home and placed his/her nursing bag on P 6s chair without a protective barrier. P 6s blood pressure was checked with a manual blood pressure (BP) cuff on the left upper arm and post usage RN 1 failed to disinfect the entire BP cuff and BP cuff carrier prior to exiting P 6s home. During an interview on 07/25/23 at 12:01 PM with RN 1 stated, ";I had training about bag protocol and another on infection control. We are supposed to use a chux pad or towel". Review of RN 1s ";Orientation Checklist" on 07/27/23 at 11:45 AM revealed ";Home Care Bag Technique" training was completed on 03/15/23 and ";Infection Control" training was completed on 03/15/23. Facility policy, entitled ";Home Care Bag Protocol Job Aid" revealed, ";7. After entering the patients home, place the bag on a clean, dry surface and a barrier placed between the bag and the surface...14. Never return soiled equipment to the bag. Items such as stethoscopes shall be cleaned per policy/procedure and allowed to dry prior to returning them to the bag...". Observation on 07/25/23 at 8:47 AM to 9:21 AM of P 7 revealed P 7 was admitted to the hospice on 05/17/23 for Atherosclerotic Heart Disease. Observation of P 7 revealed HA 1 rolled P 7 to his/her room from out of the hallway, closed the room door behind, washed and dried his/her hands and donned a pair of clean gloves. P 7 was assisted via wheelchair to his/her shower in his/her room by HA 1. HA 1 then washed, rinsed off and dried off P 7s body with the gloves donned prior to the shower. HA 1 then applied lotion to P 7s legs and arms with the same dirty gloves donned. During an interview on 07/25/23 at 9:25 AM, HA 1 stated, ";I know I should have changed my gloves, but I couldnt remember where because I have been doing this for over twenty years". Review of HA 1s ";Orientation Checklist" on 07/27/23 at 12:00 PM revealed ";Infection Control" training was completed 10/02/22. Facility policy, entitled ";Standard Precautions" revealed, ";Change gloves between tasks and procedures on the same patient and after contact with material that may contain a high concentration of microorganisms...". On 7/25/23, at 10:00 AM, a home visit was made to Patient 9 with Hospice Aide (HA) 2. HA 2 was observed providing a bed bath to Patient 9. HA 2 bathed Patient 9 with gloved hands, including perineal care after a bowel movement. HA 2 removed gloves and re-entered the nursing bag multiple times without performing hand hygiene. After the visit, during an interview with HA 2 she/he stated she/he had left her/his hand sanitizer in the car. On 7/27/23, during an interview with the Director of Clinical Services (DCS), she/he confirmed hand hygiene should be done each time before re-entering the nursing bag.

Based on record review and interview, the hospice failed to ensure the Registered Nurse (RN) performed aide supervisory visits no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide for 3 of 14 patient charts reviewed. (Patient 9, 11 and 17). --- The findings include: Record review on 07/25/23 at 3:11 PM of P 11 revealed P 11 was admitted to the hospice on 09/20/22 for Oropharynx Cancer Stage IV. Review of RN ";Visit Note Reports" revealed no aide supervisory visits on 06/05/23, 06/19/23 and 06/28/23. An RN supervisory visit was completed on 07/05/23, which was 30 days since the last supervisory visit. During an interview on 07/27/23 at 11:43 AM, the Hospice Regional Quality Coordinator verified the findings. Record review on 07/26/23 at 1:53 PM of P 17 revealed P 17 was admitted to the hospice on 05/12/23 for Hypertensive Heart Disease. Review of RN ";Visit Note Reports" revealed no aide supervisory visits on 05/17/23, 05/23/23 and 05/31/23. An RN supervisory visit was completed on 06/06/23, which was 24 days since the last supervisory visit. During an interview on 07/27/23 at 12:20 PM, the Hospice Regional Quality Coordinator verified the findings. On 7/26/23, at 9:15 AM Patient 9's record was reviewed. Patient 9 was admitted to hospice on 8/17/21 with a diagnosis of Cerebrovascular Accident (CVA). Review of the certification period 6/8/23 to 8/6/23, revealed Patient 9 was receiving Hospice Aide (HA) services 1 time per week for one week, two times a week for eight weeks and beginning 6/27/23, five times a week. The only HA supervisory visit by an RN from 6/8/23 to 8/6/23 was on 7/19/23. There was no documented evidence of HA supervision by the RN every 14 days. On 7/27/23 at 11:22 AM, during an interview with the Director of Clinical Services (DCS), she/he confirmed the findings.

Based on record review and interview, the hospice failed to ensure a written agreement was obtained for the services of staff (SN and HA) from another certified hospice to provide care for the hospice's patients. --- The findings include: Review of the hospice's patient weekly assignment sheet on 07/24/23 at 12:45 PM revealed Licensed Practical Nurse (LPN) 1 and Hospice Aide (HA) 1 assigned to patient for this hospice and another hospice. During an interview on 07/28/23 at 12:25 PM, the Business Office Manager (BOM) stated, ";We dont have a contract for the employees from another hospice because all of the hospices and staff are under the umbrella of our organization. So, we are borrowing them to see patients because we are in the midst of a merger".

Based on observation, record review, and interview, the hospice failed to ensure the entries on a nursing visit note were clear and complete and in accordance with accepted standards of practice when Registered Nurse (RN) 2 documented information different than what she/he did for one of four home visits (Patient 8). --- The findings are: On 7/25/23 at 11:05 AM, a home visit was made with Registered Nurse (RN) 2 to Patient 8. Patient 8's caregiver (CG)/ responsible party (RP) stated Patient 8 "...had a bad fall..." Patient 8 stated he/she had pain and "...bruising...all in here..." to his/her right chest "...where the cancer is...". Patient 8 placed his/her left hand on his/her right chest and right torso under his/her right arm when he/she stated this. Patient 8 was wearing a shirt, and RN 2 did not observe the area under the shirt where Patient 8 indicated. On 7/26/23 at 9:00 AM, Patient 8's record was reviewed. Patient 8's Hospice Certification and Plan of Care for the benefit period 5/10/23 to 7/8/23 showed, "...THE PRINCIPAL HOSPICE DIAGNOSIS IS SARCAMATOID MESOTHELIOMA (lung cancer) STAGE IV...MASSES IN CHEST CAVITY BETWEEN RIBS 3/4 AND 4/5, LINING TO HEART AND LYMPH NODES...". On 7/27/23 at 10:48 AM, an interview was conducted with the Director of Clinical Services and a concurrent review of the nursing visit note dated 7/25/23. The note showed, "...WAS INTEGUMENTARY ASSESSED?...YES...INDICATE INTEGUMENTARY ASSESSMENT FINDINGS...BRUISING...INDICATE LOCATION OF BRUISING...R (right) CHEST..." RN 2 documented she/he observed Patient 8's integumentary (skin) at the right chest area. The surveyor observed the entire nursing visit with RN 2 who did not observe Patient 8's integumentary at the right chest/torso area. The DCS confirmed the nursing assessment documentation should be accurate.

Based on record review, interview, and review of hospice policy and procedure, the hospice failed to ensure 1 of 2 patient death charts reviewed contained documentation for controlled medication disposal. (Patient 3) --- The findings include: Record review on 07/25/23 at 1:10 PM for Patient 3s chart revealed the patient was admitted on 02/07/23 for Chronic Obstructive Pulmonary Disease (COPD) and expired on 05/30/23. Further review of the chart revealed there was no documentation of a medication disposal form completed after the patients death with a witness of the disposal for Fentanyl Transdermal patch 25 mcg (microgram)/hr (hour), Hydrocodone 5 mg (milligram)-Acetaminophen 325 mg tablets, and Morphine Concentrate 100 mg/5ml (milliliter) (20 mg/ml. During an interview on 07/27/23 at 10:37 AM, the Hospice Regional Quality Coordinator verified the findings. Hospice policy, entitled, ";Medication Management", revealed, ";B. Disposal of Patient controlled Substances by the Hospice Agency...3. The nurse will document in the medical record if the patient/caregiver accepts or refuses the hospice agency to assist with the disposal of the controlled substance(s)...5. When hospice medications are disposed of in the presence of a hospice nurse, the disposal must be witnessed by the nurse, the patient/caregiver, and/or another employee of the hospice or facility (for facility patients). The witnessing of the medication disposal should be documented. 6. The hospice nurse will document in the patients medical record the medication name, dosage, route, quantity, method of disposal, date and time of disposal, who disposed of the controlled substance(s), and who witnessed the disposal...".

Based on record review, interview, and review of the hospice policies, the hospice failed to provide inpatient respite for one of four home visited patients (Patient 9). --- On 7/25/23 at 3:25 PM, a home visit was made with the Hospice Aide to Patient 9. During the home visit, Patient 9's caregiver (CG) and responsible party (RP) stated she/he was Patient 9's full-time caregiver and she/he had requested respite care in November of 2022 so she/he could attend a family members wedding. Patient 9's CG/RP stated she/he was told by the hospice that they were unable to provide respite for the patient. Patient 9's CG/RP stated that because the hospice told her they did not have a respite bed for Patient 9 and suggested she pay out of pocket for 24 hour care, she hired caregivers. On 7/26/23 at 9:15 AM, Patient 9's record was reviewed. The record revealed Patient 9 was admitted on 8/17/21 with a diagnosis of Cerebrovascuar Accident (CVA, e.g. stroke). The Medical Social Worker (MSW) Client Coordination Note Report, dated 9/15/22, revealed, "...PT'S (patient's) (CG/RP) REQUESTED RESPITE FOR NOV 17-21...LMSW EXPLAINED CURRENT RESPITE SITUATION AND PROVIDED OPTION OF PAYING TO STAY AT (name of SNF) OR HAVING FAMILY STAY WITH PT IF RESPITE IS UNAVAILABLE...". On 7/27/23 at 11:20 AM, during an interview with the Director of Clinical Services (DCS), she/he confirmed there was no documented evidence the hospice attempted to secure a respite bed for Patient 9 in November 2022. On 7/28/23, hospice policy, titled, "INPATIENT RESPITE CARE," revealed, "...Respite care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons who normally care for the individual at home...Examples of appropriate respite care...Caregiver attending a wedding, graduation, or other special event...".